1 Division of Nutrition, Physical Activity, and Obesity Impact of behavioral design strategies on patrons’ food choices in a US Army hospital cafeteria Dina Nugent, PhD Research Scientist, Gretchen Swanson Center for Nutrition (Study completed as a post-doctoral fellow for Division of Nutrition, Physical Activity, and Obesity, CDC) August 25, 2020
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Division of Nutrition, Physical Activity, and Obesity
Impact of behavioral design strategies on patrons’ food choices in a US Army hospital
cafeteriaDina Nugent, PhD
Research Scientist, Gretchen Swanson Center for Nutrition
(Study completed as a post-doctoral fellow forDivision of Nutrition, Physical Activity, and Obesity, CDC)
August 25, 2020
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
> 60% of active-duty military overweight or obese
¼ of new applicants medically disqualified due to excessive weight
Obesity prevalence considered a security threat to readiness
$3.3 billion per year spent in attributable health care costs among active duty personnel and military families
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Background
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
• Go for Green® (G4G) is a joint-service performance-nutrition initiative that improves the food environment where Military Service Members live and work.
• G4G uses behavioral design (e.g., color-coding, choice architecture, branding) and menu reformulation to improve food choices.
• Dual process theory and behavioral economics (e.g., Type 1/hot/fast/impulsive vs. Type 2/cold/slow/deliberate)
• The utilization of behavioral design is similar to food marketing environments, which use 4P’s (price, promotion, placement, product) to capitalize on individuals making Type 1 decisions
Background
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
• Can public health practitioners use similar approaches to create environments in which individuals make healthierchoices?
• Behavioral design or ‘nudges’ target automatic, heuristic decision-making by altering environmental cues, to improve food choice while maintaining the freedom to choose (i.e., without restricting choice).
Background
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Aim• We determined the effect of implementing G4G’s
behavioral design strategies on food purchases in a dining facility (DFAC).
• No changes to recipes were made.
Background
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
• Quasi-experimental design - one group, repeated measures• Collected Point-of-Sales (POS) data for 45 weeks
Study Overview
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Stage 1 Stage 2 Stage 3 Stage 4Formative research and
development of intervention strategies
Baseline data collection Intervention implementation
Post-intervention data collection and
feasibility study
October 2016 – April 2017
April – August 2017 August – December 2017
January – March 2018
• Intervention development meetings with DFAC dietitians
• BD strategy selection• Menu board, color-
coded labels, and signage development
• Implementation Manual of Procedures (MOP) development
• Re-coding of 200+ foods
• Food service staff training
• Environmental scans (n=3)
• Point-of-sale data collection (18 weeks)
• Implementation of 11 behavioral design strategies with correction and reinforcement by cafeteria management
• Environmental scans (n=6)
• Point-of-sale data collection (18 weeks)
• Intervention strategies no longer reinforced or corrected by cafeteria management
• In-depth interviews with food service managers and staff
• Environmental scans (n=2)
• Point-of-sale data collection (9 weeks)
Setting
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
• Eisenhower Army Medical Center (EAMC), Ft. Gordon, GA • 99 bed hospital with 3000-5000 employees
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Setting
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
• 60 DFAC staff • Average 32.4K in sales per month• Civilians & active military
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
• 10 no- or low-cost environmental changes • Developed by CDC & DFAC dietitians• Implemented by DFAC staff for 18 weeks• Evaluated by CDC BD Strategies
1. Menu Board Redesign
2. Featured ‘Performance’ Plate of the Day
3. Salad Bar Redesign
4. Hot Station Redesign
5. Short Order Bar Redesign
6. Multiple Fruit Displays
7. Chip Display
8. Healthier Drink Fountains
9. Refrigerated Vending Placement
10. Communications Messaging
Intervention Overview
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
A Healthy Start for Infants
Color Coding of Foods
Attempt #1: • Recode 200+ recipes using G4G algorithm
Attempt #2:• 4 Dietitians• Consensus on appropriate code for each item
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Menu Board Redesign
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Performance Plate
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Salad Bar Redesign
Children & Youth Growing Up Strong
& HealthyA Healthy Start
for Infants
Green ----------------------------- > Yellow ----------------------------> Red Salad Bar Sign
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Hot Food Line
Children & Youth Growing Up Strong
& Healthy A Healthy Start for Infants
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Communications Messaging
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Vending Redesign & Fruit Baskets
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Measures
Point of Sales Reports from MICROS
Apr 17, 2017to Feb 23, 2018
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Volume sales trends of coded foods
Hot Entrees Green, Yellow, RedHot Vegetables GreenHot starches Green, Yellow, RedWhole Fruit, Fruit Cups GreenPies, Cakes, Brownies RedTo-go Salads GreenFrench Fries Red
*Standardized by total sales volume to control for differences in overall sales over the study period
Sales trends of 15 time-points (1 time-point = 1 menu cycle/3-weeks)
Data Analysis
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
Green Entrée Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
Yellow Entrée Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
Red Entrée Sales
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Hot Vegetable Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Hot Starch Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
French Fry Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Whole Fruit Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Cakes, Cookies, and Pie Sales
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Children & Youth Growing Up Strong
& Healthy
A Healthy Start for Infants
Data Analyses
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Adjusted models
1) T-test comparison: Compared mean weekly sales of each food outcome (adjusted for total weekly sales of all foods) between the pre-intervention period and the intervention period.
2) Log-linear regression model: Adjusted for total weekly sales volume, menu cycle week, season of the year, time trend, and special holiday meals
Table 1. Mean adjusted weekly unit sales (#) of selected foods during baseline, and intervention, and multivariable adjusted percent (%) change from baseline to intervention period
• BD strategies (e.g., placing hot vegetables at grill station) was effective to increase sales of vegetables
• BD strategies (e.g., prominent placement of fruit, less prominent placement of desserts) were effective to reduce sales of cookies, cakes, and pies, and increase sales of fresh fruit.
• Green-, yellow-, and red-entree sales did not significantly change.
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Limitations
Intervention
• Food waste (e.g., unanticipated changes to decrease food waste)• Not enough leadership buy-in to sustain at follow-up
Data Collection
• Point-of-sale system• Burdensome for dietitians• Sales ≠ Consumption
Interpretation• No control group, cannot eliminate all confounders (e.g.,
unexpected/unknown changes in food service operations)
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Strengths
Intervention• Implemented by food service staff as a part of normal job
duties (feasible for long-term)• High fidelity• Relatively ‘Low-cost’
Data Collection• Sales data (not a recall)• Collected sales at multiple time points (time series)
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Discussion & Next Steps
• Low-cost BD strategies were effective to change some food purchasing behaviors among hospital cafeteria patrons.
• Changes were relatively small and warrant adjunct strategies (e.g., pricing, recipe reformulations) to improve dietary quality or health outcomes over time.
• Buy-in from food service staff is essential for sustainability.
• Unintended consequences (e.g., food waste, substitution effects) of BD strategies should be anticipated to prevent an overall caloric increase and/or revenue loss.
• Study should be replicated with a control group, and with adjunct strategies (e.g., factorial design).
Background & Aims
Study Overview & Intervention
Measures Findings Discussion
Acknowledgements
Ft Gordon food service staffDr. Steve OnufrakDr. Seung Hee Lee